Transcript IBD and the Brain Eva Szigethy MD, PHD Associate Professor

Management of psycho-social
issues in IBD patients: Case series
Eva Szigethy MD, PHD, FACG
Associate Professor of Psychiatry, Pediatrics and Medicine, University
of Pittsburgh
Marla C. Dubinsky MD
Division Chief, Pediatric GI and Hepatology, Mount Sinai Hospital
December 5,2014
Disclosure: Szigethy
• Sources of Funding
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CCFA Senior Investigator Award
NIMH R01 Grants
American Psychiatric Press Inc., Book Editor
Merck- Consultant, Advisory Board
AbbVie- Consultant, Advisory Board
GI Health Foundation- Honorarium
iHope Network Inc. Scientific Advisor
• All medication suggestions in this presentation are
off-label uses unless noted otherwise.
Disclosure: Dubinsky
• Consultant for
–Janssen, Abbvie, UCB, Pfizer, Takeda,
Shire, Genentech, Prometheus Labs,
Salix
Objective
• Use case examples to illustrate key diagnostic
and treatment decisions in addressing
psychosocial concerns in patients with IBD
– Anxiety
– Depression
– Chronic Pain
Case # 1: “I can’t stop worrying about
getting sick again”
• 13 year old female (Ann) with inactive ulcerative colitis
presents with extreme anxiety about having a flare which
significantly worsened over the past year.
• ᵠsxs: worrying, restless, muscle tension, poor sleep,
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avoidance of public bathrooms, less social with friends
due to worry about not being accepted.
Diagnosed with IBD when she was 5 years old
Current medications: Azathioprine
No past medical or psychiatric history
Social history- good social support, intact family, adequate
functioning in school.
Spectrum of Anxiety Psychopathology
in IBD
Ann
• Mild
• Age appropriate
worry
• Adjustment
disorder
• Sick role behavior
(parental modeling
Functioning OK
Moderate
• Generalized
Anxiety
Disorder
• Panic Attacks
• Illness Anxiety
Disorder
(somatization)
Severe
• Obsessive
compulsive
disorder
• Panic attacks
• Post traumatic
stress disorder
Poor functioning (avoidance)
Generalized Anxiety Disorder (GAD)
• Excessive worry (apprehensive expectation)
about several events or activities for at least 6
months
• At least 3 of following symptoms:
– Restless
– Fatigue
– Concentration
– Irritable
– Muscle tension
– Sleep disturbance
Behavioral Interventions First
• Listening to Ann process experience with IBD in
empathic.
• Cognitive behavioral therapy for 8-12 sessions over 3
months to teach Ann:
– Relaxation techniques to target autonomic arousal
– Cognitive restructuring to alter anxious reactions to
anxiety provoking situations (socializing with friends)
– Graduated controlled exposure tasks to prevent avoidance.
• Family education
• 70% response rate after 3-6 months of behavioral
treatment
Augmentation with antidepressant
• Ann has 50%
improvement in anxiety
but now is starting to
avoid school due to
anxiety about upcoming
colonoscopy.
• Add Fluoxetine (SSRI)
up to 40 mg by week 12
or Sertraline 100150mg by week 8
• If no response, switch
to Venlafaxine (SNRI) up
to 225 mg by week 12.
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Possible Side Effects
Activation common 1015%
Bipolar switch
uncommon (< 1%)
GI side effects early
Easy bruising and
bloody noses
Suicidal activation
Ann’s case continued:
• Ann’s mother reports that she woke up during a
colonoscopy 4 years ago and was extremely nervous
about it then but now over past 3 weeks has started to
have nightmares about it and is saying she is going to
refuse the upcoming colonoscopy. She has also become
more tense and irritable.
• Consider acute stress disorder or reactivation of
perceived “traumatic” event- Traumatic or Stress DO
– Re-experiencing
– Avoidance
– Hyperarousal
• In DSM-5- PTSD no longer anxiety disorder. Unspecified
Trauma and Stressor-related Disorder now also a
consideration.
Treatment plan for Ann
• SSRIs can cause activation and nightmares so may
consider lowering her dose.
• School 504 plan to facilitate school attendance
• Add trauma-focused elements to her cognitive
behavioral therapy
– Education about trauma and reactions
– Additional relaxation techniques (hypnosis)
– Help her identify feelings and tell her story while
creating corrective narrative
– In vivo mastery of trauma reminders
• Consider post-poning colonoscopy if feasible
Medications for Pediatric PTSD
• There are no “magic pills” for PTSD.
Medications are used to target specific
persistent symptoms.
• Mood stabilizers (Lamotrigine) for irritability
• Beta blockers (propranolol) or alphaadrenergic agonists (guanfacine) for
hyperarousal.
Which team member to diagnose and
treat?
Psychiatrist-psychiatric medication and complex case consultation
Severe
Psychologist-behavioral management and
coordination
Moderate
Social worker- life management and team
coordination; transition of care; caregiver
burnout
GI Nurses- Medical education
Mild
Gastroenterology- Medical decisionmaking
©Szigethy and Regueiro 2014
Case #2 “ I just want to die. I feel like
such a freak compared to the other kids”
• 16 year old male (Joe) with Crohn’s disease
who presents depressed and suicidal.
• Diagnosed at age 13. Initial good response to
infliximab but lost response and required
surgical resection 1 year ago.
• Ongoing active disease (inflammation) and
just learned that his ostomy will not be
reversed.
• Denies pain or other medical symptoms.
Joe’s depressive symptoms
• Irritable mood
• Anhedonia (no pleasure
or motivation
• Poor sleep
• Fatigue
• Low self-esteem
• Suicidal (no plan or
previous attempts)
• No guns at home
• Switched to home
schooling and social
isolation from friends
• No previous psychiatric
history
• Denies alcohol or drug
use including marijuana
• Negative family
psychiatric history
Spectrum of Depressive
Psychopathology in IBD
Joe
• Mild
• Age appropriate
mood lability
• Adjustment
disorder
• Brief sickness
behavior during
acute IBD flare
Moderate
• Major
Depression
(>2 weeks)
• Dysthymia
(> 1 year)
• Chronic
sickness
behavior +/IBD flare
Severe
Major depression
with suicidality
+/Comorbid
psychiatric
disorder
+/Extreme life stress
(ostomy)
Suicide Assessment:
Root Cause Chain Analysis for Suicide
• Identify series of events that led to recent
suicidal crisis
• Aims to identify Joe’s precipitating thoughts,
feelings, and actions
Joe’s Case:
Hate IBD
embarrassed by ostomy
love interest for prom
wants to die
rejected by
Treatment Steps for Joe
• Treat underlying inflammation- GI team
• Facilitate education about ostomy and help Joe process
his story but “I don’t want to talk about it” common.
• Psychotherapy (12-20 sessions) to help him problemsolve using cognitive behavioral therapy.
– Root cause chain analysis, Safety planning, education,
reasons for living
– Cognitive behavioral skills training, family work
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Activity Selection
Goal-setting
Problem-solving training
Identify and alter negative cognitive distortions
• 65% of depressed/suicidal patients respond to
psychotherapy alone
Stanley 2009; Maalouf & Brent, 2012; Szigethy 2012; 2014
Medication decisions for depression in
pediatric IBD
• If inactive IBD.......then SSRI first line if does not
work switch to different class SNRI (duloxetine
20-40mg)
• If active IBD………then bupropion first line (150300mg)
• If comorbid pain….then SNRI first or low dose TCA
added
Case # 3: “The pain is constant and ruining my life. I
hate how they treat me like an addict when I go to
the ER for relief.”
• 28 year old female (Sue) with inactive Crohn’s disease but over
past year abdominal pain is constant, “10 out of 10 severity”.
• Mild increase in pain with eating. No change with defecation.
Had intermittent pain with disease activity in past. This new
bout of constant pain started after C-diff infection.
• CD diagnosed 4 years ago. No surgeries.
• Medications: Fentanyl patch and oxymorphone pills prn x 6
months. Citalopram-started 1 year ago for pain, 6-MP
• Other pain syndromes- fibromyalgia and chronic headaches.
No other medical diagnoses.
• Patient goes to multiple ERS to get narcotics and "fights" with
staff/MDs when time comes to cut down meds.
• Feels depressed and fatigue but no current psychiatric
diagnoses. Pain also interferes with sleep.
Sue’s formulation
• Has many characteristics of “central” pain
prone phenotype (CNS mediated pain)
– Female, history of other chronic pain syndromes,
catastrophizing
– Also assess for early life trauma
• IBD-IBS pain from peripheral nerve
sensitization after C-diff exposure also
possible.
• Need to assess if narcotic use has evolved into
substance abuse/dependence.
Spectrum of Pain Psychopathology in
IBD
SUE
• Mild
• Brief pain related to
gastroenteritis or
IBD flare (CD > UC)
• Sick role behavior
(parental modeling
Moderate
Severe
• IBD- IBS (irritable
bowel syndrome)possible postinfectious
Central chronic pain
+/Multiple pain syndromes
+/-
• Somatic symptom
disorder
(somatization)
Childhood trauma
+/Psychopathology
+/Narcotic use
Treatment Plan for Sue
• Build a strong therapeutic relationship to improve
motivation and educate about neurobiology of
pain circuits.
• Teach behavioral interventions for pain
management- distraction techniques and
hypnosis so “brain” can be less reactive to “false
alarm” pain signals.
• Behavioral sleep interventions and sleep hygeine
• Begin appropriate alternative non-opioid pain
medications.
• Explore willingness to come off opiates
Concerns with Opiates in IBD
• No evidence of efficacy
for chronic abdominal
pain
• Psychological/physical
dependence
• Higher rates of
infection/mortality
• Narcotic Bowel
Syndrome (NBS) versus
Tolerance
Grunkmeier 2007; Lichenstein 2006;
Non-opioid pharmacotherapy for Sue
• SSRIs (citalopram) can help anxiety and
depression but rarely help pain directly.
• Add a tricyclic antidepressant at night.
• Start low and go slow. Usual dose range
between 50-150 mg/day
• Analgesia starts to occur after a week and can
take 3 weeks to reach max efficacy.
• Amitriptyline (3 ◦) more sedating
• Nortriptyline (2◦) less sedating
• Desipramine (2◦) least sedating
Drossman 2009; Dekel 2013; Szigethy & Drossman 2014
Other Pharmacological options (off-label):
Visceral Pain
CLASS
TYPE
MECHANISMS for PAIN CONTROL
Antidepressants
TCAs
Increased SE, endogenous opioid
release, anti-inflammatory?
SNRIs
Stimulants
Methylphenidate
D-amphetamine
Influence NE, SE, DA, endogenous
opioids
Mood stabilizers Gabapentin/pregabalin Central voltage-gated calcium
channels?
Atypicals
Quetiapine?
DA, SE, Adrenergic antagonism
Glutaminergic
Memantine ?
Glutamate antagonism
Antiinflammatory
Doxcycline ?
Central or peripheral inflammation
Ford, 2008; Drossman 2002; Taylor 2007; Houghton 2011; Grover 2009; Szigethy and
Drossman, 2014
Opioid Detoxification for Sue
• Attempt outpatient taper but inpatient medical
hospitalization if necessary
• 10-33% daily reduction of i.v. morphine or
hydromorphine equivalent
• Clonidine for withdrawal symptoms
• Benzodiazepines for extreme anxiety
• Continue non-opioid pain medications
• Appropriate management of bowel motility
(constipation or diarrhea)
• Continue behavioral interventions
• 70% success rate but high recidivism at 3 months
if aggressive non-opiate pain management not
continued.
Rational Approach to Chronic pain
• Address false expectations or beliefs of patients
• Provide neurobiological explanation of patient’s
symptoms that psychopharmacological agent
would target
• Provide information/rationale aligned with
patient’s interests/concerns
• Negotiate treatment plan
– Benefit in 4-6 weeks
– Most side effects decrease in 1-2 weeks
– Consider previous drugs that works and family history
of drug response
Personalized Psychosocial
Management Pathways
Active IBD
IBD Meds
Inactive IBD
Coping
therapy
Cognitive
behavioral
therapy
Hypnosis
Psychotropic
medication
Psychotropic
medication
Exercise